Michele Meyer

 shows that babies born to mothers with disabilities are more likely to die or suffer complications, which often leads to costly medical care post-birth. 

The investigators conducted a large-scale, population-based cohort study spanning 1,069,388 births in Ontario, Canada. Females aged 15-49 years who gave birth to both live and stillbirth babies born between 2003 and 2017 were followed from conception to delivery.

Toronto’s Institute for Clinical Evaluative Sciences provided the health and demographic numbers for Ontario province’s 14.7 million residents.

The researchers compared prenatal care between women without disabilities (n=953,766) and with disabilities (n=115,622).

The latter were split into groups—sensory (vision or hearing loss), physical (including musculoskeletal and neurologic), intellectual/developmental (including autism spectrum disorder, fetal alcohol spectrum disorder, and autosomal or chromosomal anomalies), or multiple disabilities.

The Revised Graduated Prenatal Care Utilization Index

 determined the adequacy of physician visits, as none (0 visits), fewer than recommended (1 to 10 visits), recommended (11 to 14 visits), and more than recommended (15 or more visits).

Those guidelines suggested the first appointment with a family physician or obstetrician occur within 8 to 10 weeks of pregnancy. Gestational age was judged by first trimester ultrasound in 70% of cases and last menstrual period in the remainder.

Qualitative studies suggest that—as with very young or low-income women

—these mothers face barriers to prenatal care, such as inaccessible spaces, negative attitudes among providers, and lack of resources tailored to their needs.

That can lead to delays in starting prenatal care and fewer visits overall—both dangerous to babies’ health.

“Adequate prenatal care reduces risks of adverse perinatal outcomes, such as preterm birth, and perinatal mortality,” noted Fareha Nishat, MPH, University of Toronto, lead author of the study.

The researchers examined this understudied group to determine if the type of disability made a difference in mothers seeking prenatal care—and found that it did.

Despite Canada’s universal health care—with no-cost prenatal visits—those with disabilities were treated differently.

“Particular vulnerability was observed in women with intellectual/developmental disabilities,” the study authors wrote. Those mothers were least likely to get timely and sustained prenatal care. Along with women with hearing loss, those mothers were late to see a doctor and then sought care fewer than recommended times.

Those with physical disabilities, compared to those without, had increased odds of intensive prenatal care (AOR=1.22, 95% CI=1.19, 1.24) and decreased odds of no prenatal care (AOR=0.94, 95% CI=0.89, 0.99) vs adequate care.

Women with sensory disabilities had increased odds of intensive (AOR=1.11, 95% CI=1.08, 1.14), inadequate (AOR=1.06, 95% CI=1.02, 1.09), and no (AOR=1.24, 95% CI=1.14, 1.35) prenatal care.

Women with intellectual/developmental disabilities had increased odds of inadequate (AOR=1.25, 95% CI=1.08, 1.44) and no (AOR=1.64, 95% CI=1.16, 2.34) prenatal care.

Women with multiple disabilities had increased odds of intensive (AOR=1.41, 95% CI=1.32, 1.51) and inadequate (AOR=1.14, 95% CI=1.05, 1.22) prenatal care.

Given the high rates perinatal complications, “inadequate prenatal care in this population is a lost opportunity to address modifiable risk factors, such as chronic disease management, smoking, and obesity,” the authors noted.

They urged ob-gyns to collaborate with women having disabilities—10% of reproductive age females—on better addressing their needs and access to care, and not just in Canada.

“Only1 population-based study of 33,383 US women with disabilities and 6.4 million without disabilities has directly examined the relationship between disability and prenatal care adequacy,” the authors noted.

“(Our) findings show the need to address barriers to timely and sustained prenatal care among women with disabilities,” they said, recommending health care provider training and longer appointments. “Services should be inclusive, accessible, and respectful so that women with disabilities maintain autonomy and dignity.” 

MacKay AP, Berg CJ, Atrash HK. Pregnancy-related mortality from preeclampsia and eclampsia. 

. 2001;97(4):533–538. doi:10.1016/S0029-7844(00)01223-0

Alexander GR, Kotelchuck M. Quantifying the adequacy of prenatal care: a comparison of indices

. 1996 Sep-Oct;111(5):408-18; discussion 419. PMID:8837629; PMCID:PMC1381783

Schuurmans N, Blake J. Healthy beginnings: Giving your baby the best start, from preconception to birth.; 2017. Accessed February 11, 2022. 

https://search.ebscohost.com/login.aspx?direct=true&scope=site&db=nlebk&db=nlabk&AN=1475503

Kilpatrick SJ, Papile LA, Macones GA, eds. Guidelines for perinatal care. 8th ed. Itasca, IL: American Academy of Pediatrics. 2017. https://ebooks. aappublications.org/content/9781610020886/9781610020886. Accessed July 9, 2021.

You JJ, Alter DA, Stukel TA, et al. Proliferation of prenatal ultrasonography. 

. 2010 Feb 9;182(2):143-51. doi:10.1503/cmaj.090979. Epub 2010 Jan 4. PMID:20048009; PMCID:PMC2817321

Heaman MI, Martens PJ, Brownell MD, et al. Inequities in utilization of prenatal care: a population-based study in the Canadian province of Manitoba. 

. 2018 Nov 1;18(1):430. doi:10.1186/s12884-018-2061-1. PMID:30382911; PMCID:PMC6211437

Mitra M, Parish SL, Clements KM, Cui X, Diop H. Pregnancy outcomes among women with intellectual and developmental disabilities. 

. 2015 Mar;48(3):300-8. doi:10.1016/j.amepre.2014.09.032. Epub 2014 Dec 26. PMID:25547927

Partridge S, Balayla J, Holcroft CA, Abenhaim HA. Inadequate prenatal care utilization and risks of infant mortality and poor birth outcome: a retrospective analysis of 28,729,765 U.S. deliveries over 8 years. 

. 2012 Nov;29(10):787-93. doi:10.1055/s-0032-1316439. Epub 2012 Jul 26. PMID:22836820.

Tarasoff LA, Ravindran S, Malik H, Salaeva D, Brown HK. Maternal disability and risk for pregnancy, delivery, and postpartum complications: a systematic review and meta-analysis. 

. 2020 Jan;222(1):27.e1-27.e32. doi:10.1016/j.ajog.2019.07.015. Epub 2019 Jul 12. PMID:31306650; PMCID:PMC6937395

Centers for Disease Control and Prevention (CDC). Prevalence and most common causes of disability among adults--United States, 2005. 

. 2009 May 1;58(16):421-6. PMID:19407734.

Horner-Johnson W, Biel FM, Caughey AB, Darney BG. Differences in prenatal care by presence and type of maternal disability. 

. 2019 Mar;56(3):376-382. doi:10.1016/j.amepre.2018.10.021. PMID:30777157; PMCID:PMC6402767

Renfrew MJ, McFadden A, Bastos MH, et al. Midwifery and quality care: findings from a new evidence-informed framework for maternal and newborn care. 

. 2014 Sep 20;384(9948):1129-45. doi:10.1016/S0140-6736(14)60789-3. Epub 2014 Jun 22. Erratum in: Lancet. 2014 Sep 20;384(9948):1098. PMID:24965816

Articles

A study published in American Journal of Preventive Medicine compared prenatal care in women with various disabilities.

Women’s disabilities affect likelihood of prenatal care and negative outcomes

A new consensus, published in Women’s Health Reports, offers a clear roadmap to mycologic (fungal) cure for the 1 in 10 women who suffer recurrent vulvovaginal candidiasis (RVVC)

 specializing in RVVC met to develop guidelines for the condition’s effective and safe maintenance, given the lack of one offered by the US Centers for Disease Control and Prevention.

“The CDC does not provide recommendations for the type or frequency of topical maintenance, leaving clinicians without templates regarding best practice,” says lead author Nancy A. Phillips, MD,

Topical Treatment of Recurrent Vulvovaginal Candidiasis: An Expert Consensus

The group concluded that women with RVVC should be treated longer than those with non-recurrent VVC, starting with initial treatment of 7 to 14 days of topical therapy—versus 1-7 days—or 3 doses of fluconazole, with 100-, 150- or 200-mg. taken by mouth once every 3 days.

The type of yeast should be confirmed before treatment. Oral flucoconazole is ineffective against 

 yeast, the cause of 1 in 5 fungal infections.

The doctors suggest 6 months of maintenance doses 1 to 3 times weekly—usually twice weekly—of topical azoles (clotrimazole, miconazole and terconazole) against 

 fungi, unless terconazole worked for the patient previously.

Contributing factors to recurrent infections also should be addressed, such as intrauterine devices and diabetes. Ideally, diabetic patients should control blood sugar with drugs other than sodium glucose cotransporter two inhibitors (SGLT2).

 Corticosteroids and antibiotics should be minimized.

The panel also raised risks of some drugs.

Oral fluconazole can endanger women who are on statin drugs, have kidney disease or are at risk for arrhythmias.

It also can cause miscarriages. Indeed, a 2015 nationwide cohort study in Denmark showed a significantly higher chance of miscarriage and stillbirths in women taking oral fluconazole versus those who did not or who used a topical azole.

Intravaginal boric acid and ibrexafungerp, an oral drug the US Food and Drug Administration approved last June,

Only 7-day azoles should be used during pregnancy or in women planning to become pregnant.

The 30-50% of women who continue to have recurrent infections after six months of maintenance treatment should see a RVVC specialist, the panel concludes.

Foxman B, Muraglia R, Dietz JP, Sobel JD, Wagner J. Prevalence of recurrentvulvovaginal candidiasis in 5 European countries and the United States: Results from an internet panel survey. J Low Genit Tract Dis 2013;17:34

Hope Haefner, MD, Department Obstetrics and Gynecology, University of Michigan University Hospital, Ann Arbor, Michigan, USA; Mark G. Martens, MD, Department Obstetrics and Gynecology, Tower Health, West Reading, Pennsylvania, USA; Colleen Stockdale, MD, MS, clinical professor in Obstetrics and Gynecology and director of Vulvar Vaginal Disease Clinic at Carver Medical School at University of Iowa, Iowa City, USA.

Nancy A Phillips and Gloria Bachmann, MDs, Department Obstetrics, Gynecology and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA.

Phillips NA, Bachmann G, Haefner H, Martens M, Stockdale C. Topical Treatment of Recurrent Vulvovaginal Candidiasis: An Expert Consensus. Womens Health Rep (New Rochelle). 2022 Jan 31;3(1):38-42. doi: 10.1089/whr.2021.0065. PMID: 35136875; PMCID: PMC8812501.

Omudhome Ogbru, PharmD. SGLT2 Inhibitors (Type 2 Diabetes Drug Class). MedicineNet. Published July 2, 2019. Accessed March 22, 2022. https://www.medicinenet.com/sglt2_inhibitors_type_2_diabetes_drug_class/article.htm

Mølgaard-Nielsen D, Svanstro ̈m H, Melbye M, Hviid A, Pasternak B., Association between use of oral fluconazole during pregnancy and risk of spontaneous abortion and stillbirth. JAMA 2016;315:58–67.

Sakoulas, G., FDA Approves Ibrexafungerp (Brexafemme) for the Treatment of 

Vulvovaginal Candidiasis, NEJM Journal Watch, June 3, 2021.

https://www.jwatch.org/na53719/2021/06/23/fda-approves-ibrexafungerp-brexafemme-treatment

A study published in Women’s Health Reports suggests best practices for treating recurrent vulvovaginal candidiasis.

Michele Meyer

Articles

Women’s disabilities affect likelihood of prenatal care and negative outcomes

Topical treatment of recurrent vulvovaginal candidiasis: an expert consensus